Date Of Birth:
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Primary Care Physician:
Relationship to patient:
Subscriber's Date of Birth:
Subscriber's Address (if different than above)
Emergency Contact Person
I grant permission to share my medical information with this contact.
I hereby acknowledge that I have received a copy of the Lori A. Heyler, OD LLC ‘s Notice of Information Practices and I understand that the notice describes how this office uses and discloses my medical and billing information.
Assignment of Insurance Benefits
I hereby authorize payment directly to Lori A. Heyler, OD LLC from my vision plan and/or health insurance. I understand that I am responsible for charges not covered by my insurance.
At Canterbury Vision Care , we provide the highest quality Optometry care to all our patients. Schedule your appointment today.